Colney Lodge Limited

The provider must ensure clear risk assessments are in place to minimise risks and safeguard people from harm, including for activities like walking to shops and fire evacuation. Emergency evacuation plans must be in place. Safeguarding and whistleblowing policies must be reviewed and staff must be aware of and follow them, including reporting incidents and updating risk assessments. Care plans must cover specific risks such as self-medication, travelling alone, and falls.

The provider must ensure medicine audits are in place. Medicine administration records (MAR) must be completed accurately and not signed ahead of time. Risk assessments must be in place for managing refusal of medication.

The provider must ensure incidents are reported to relevant agencies in a timely manner. Staff must receive regular supervision and support. Training records must be available for all staff employed at the service.

The provider must ensure people are involved in planning their care and that care documents are regularly reviewed. Care plans must be detailed, accurate, and complete, providing a true picture of the person's conditions, medication, and support information to ensure consistent care.

The provider must implement quality audits to identify errors in documentation, including care records, risk assessments, MARs, and staff files. Records must be readily available to staff when needed.

The provider must ensure all staff have current Disclosure and Barring Service (DBS) checks.

The provider must ensure all staff have an understanding of how to use the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards (DoLS) when providing care to people. People must consistently sign care documents to confirm their involvement and agreement.

The provider must ensure the manager understands and fulfils their responsibility in reporting all required issues to CQC, including incidents where people are injured or at risk of abuse or neglect.